Resistance to heparin therapy during cadiopulmonary bypass(CPB) is infrequent but can result in potentially life-threatening event. The precise etiology of the heparin resistance remains unknown. Clearly, the most predictive risk factor is a history of previous heparin exposure. Assessment of the clinical heparin effect, by determination of the activated clotting time(ACT), identifies those patients with heparin resistance. The potential risk of suboptimal anticoagulation is circumvented by the administration of additional heparin. High dose aprotinin suppress the activation of intrinsic coagulation pathway through surface activators inhibition, as documented by increases in the ACTs during CPB. Such effect of aprotinin on ACT, which can allow heparin-resistant patients to overestimate heparinization. We report a case of pump failure due to inappropriate heparinization in heparin-resistant patient.
Aprotinin ; Cardiopulmonary Bypass ; Heart ; Heparin* ; Humans ; Risk Factors

BACKGROUND: Monitoring of cellular function during acute reduction of oxygen delivery(DO2) remains controversial. Increases of arteriovenous difference in PCO2(AVPCO2) and in pH(AVpH) have been alleged to reflect development of tissue hypoxia in shock status associated with low cardiac output. Method: 6 anesthetized and mechanically ventilated pigs were bled via Swan-Ganz catheter by 10% of total estimated blood volume. In each pig, we measured the hemodynamic parameters, arterial and mixed venous blood gas analysis data and calculated O2-derived parameters during gradual blood loss from 10% to 50%. RESULT: As blood loss increased, DO2 declined from 521+/- 108 ml/min to 178+/- 125 ml/min but O2 extraction ratio(14+/- 4% to 47+/- 33%) increased. After 30% blood loss, O2 consumption decreased from 121 +/-48 ml/min to 79+/- 58 ml/min progressively but lactate level markedly increased from 22.0 +/-5.5 mg/dl to 52.7+/- 21.8 mg/dl. As DO2 decreased, AVPCO2 and AVpH( -11+/- 2 mmHg to - 27+/- 11 mmHg, 0.03+/- 0.02 to 0.11 0.04 respectively) rose, and these increases were especially more prominent after DO2 value at 30% blood loss than before(p<0.05). CONCLUSION: We demonstrated that the increases of AVPCO2 and AVpH can be reliable parameters of tissue hypoxia during gradual blood loss.
Anoxia* ; Blood Gas Analysis ; Blood Volume ; Cardiac Output, Low ; Catheters ; Hemodynamics ; Hemorrhage* ; Hydrogen-Ion Concentration* ; Lactic Acid ; Oxygen ; Shock ; Swine*

OBJECTIVE: GnRH-agonist (GnRH-Ag) used in controlled ovarian hyperstimulation (COH) for IVF-ET has been known to affect directly on apoptosis of human ovarian cells, but its mechanism is not clearly understood. Therefore, the purpose of the present study was to investigate whether caspase-3 and -9 activation and poly-(ADP-ribose)-polymerase (PARP) cleavage are involved in the mechanism(s) by which GnRH-Ag induces apoptosis in human granulosa-luteal cells. METHODS: Human granulosa-luteal cells collected from IVF-ET patients were cultured and treated with 10(-6) M GnRH-Ag or saline as a control. To access apoptosis in the cells, terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-digoxigenin nick end-labeling (TUNEL) assay and DNA fragmentation analysis were preformed 24 h after the treatment. Activity of caspase-3 and -9 in the cells was examined by using a fluorogenic substrate. Caspase-3 and -9 activation and poly (ADP-ribose) polymerase (PARP) cleavage were analyzed by Western blotting. RESULTS: DNA fragmentation in the cells increased in the higher concentration over 10(-6) M GnRH-Ag. In the result of TUNEL assay, the rate of apoptotic cells in GnRH-Ag treatment increased significantly compared with that of saline treatment (p<0.05). The activity of caspase-3 and -9 investigated by using a fluorogenic substrate increased only in the apoptotic cells. In Western blot analysis, the cells treated with GnRH-Ag revealed an increase in active forms of caspase-3 and -9 compared with those of the saline treatment. In addition, cleavage of PARP also increased in the cells treated with GnRH-Ag. CONCLUSION: These results suggest that activation of caspase-3 and -9 and cleavage of PARP might be involved in apoptosis of human granulosa-luteal cells induced by GnRH-Ag.
Apoptosis* ; Blotting, Western ; Caspase 3* ; DNA Fragmentation ; DNA Nucleotidylexotransferase ; Female ; Fluorescent Dyes ; Humans* ; In Situ Nick-End Labeling ; Luteal Cells*

OBJECTIVES: The goal of this study was to define the radiologic characteristics of two-phase computed tomography (CT) of salivary gland Warthin tumors and to compare them to pleomorphic adenomas. We also aimed to provide a foundation for selecting a surgical method on the basis of radiologic findings. METHODS: We prospectively enrolled 116 patients with parotid gland tumors, who underwent two-phase CT preoperatively. Early and delayed phase scans were obtained, with scanning delays of 30 and 120 seconds, respectively. The attenuation changes and enhancement patterns were analyzed. In cases when the attenuation changes were decreased, we presumed Warthin tumor preoperatively and performed extracapsular dissection. When the attenuation changes were increased, superficial parotidectomy was performed on the parotid gland tumors. We analyzed the operation times, incision sizes, complications, and recurrence rates. RESULTS: Attenuation of Warthin tumors was decreased from early to delayed scans. The ratio of CT numbers in Warthin tumors was also significantly different from other tumors. Warthin tumors were diagnosed with a sensitivity of 96.1% and specificity of 97% using two-phase CT. The mean operation time was 38 minutes and the mean incision size was 36.2 mm for Warthin tumors. However, for the other parotid tumors, the average operation time was 122 minutes and the average incision size was 91.8 mm (P<0.05). CONCLUSION: Salivary Warthin tumor has a distinct pattern of contrast enhancement on two-phase CT, which can guide treatment decisions. The preoperative diagnosis of Warthin tumor made extracapsular dissection possible instead of superficial parotidectomy.
Adenolymphoma* ; Adenoma, Pleomorphic ; Diagnosis ; Humans ; Parotid Gland ; Parotid Neoplasms ; Prospective Studies ; Recurrence ; Salivary Glands* ; Sensitivity and Specificity ; Tomography, Spiral Computed*

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. The purpose of this study was to determine whether measurement of intact parathyroid hormone (i-PTH) level in thyroidectomy patients could predict hypocalcemia. MATERIALS AND METHODS: We performed a prospective study of patients undergoing total thyroidectomy. Serum concentration of i-PTH, total calcium (Ca), ionized calcium (Ca2+), phosphate (P), magnesium (Mg), and albumin were measured preoperatively and at 0 hour, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours postoperatively. RESULTS: 108 patients were recruited to the study. A total of 50 patients (46%) experienced hypocalcemia. The serum i-PTH concentration was linearly related to the time of measurement, while concentrations of P, Mg, albumin, Ca, and Ca2+ were not. We compared odds ratios, and found that the concentration of i-PTH at 6 hours post operation was the most closely related to the occurrence of hypocalcemic symptom. On ROC analysis using i-PTH level at 6 hours, an i-PTH level of 10.6 mg/dL was found to maximize both sensitivity and specificity at the same time point. CONCLUSION: We found that i-PTH was a predictor of hypocalcemia, and that the earliest predictor of hypocalcemic symptoms was an i-PTH concentration lower than 10.6 mg/dL obtained 6 hours after total thyroidectomy.
Calcium/blood ; Humans ; Hypocalcemia/*diagnosis ; Magnesium/blood ; Odds Ratio ; Parathyroid Hormone/*blood ; Phosphates/blood ; Postoperative Complications/blood/*diagnosis ; Prospective Studies ; Serum Albumin ; Thyroidectomy/*adverse effects

PURPOSE: Laryngeal fracture is rare, but complications are frequent and severe. Controversy still exists in regards to its proper management. The aim of this study was to present the clinical findings and management of laryngeal fracture in Korea. MATERIALS AND METHODS: We analyzed the medical records of 22 patients with laryngeal fracture at a tertiary care trauma center from 2000 to 2010 retrospectively. RESULTS: In total, 22 patients (19 men and 3 woman) presented with laryngeal fractures caused by blunt (n=13) or penetrating (n=9) injury. Pain (68.1%), odynophagia (68.1%), hoarseness (18.1%), hemoptysis (13.6%), and subcutaneous emphysema (9%) were the common presenting symptoms and noncomminuted fracture was common. High velocity blunt trauma (mostly traffic accidents) patients had more extensive injury and poor voice outcomes. Penetrating trauma patients due to physical assault or suicide attempt demonstrated more frequently injuries on the left side. CONCLUSION: In driver-caused traffic accidents, where injuries in a wide area within the larynx occurred, poor voice results were seen, and these injuries required aggressive treatment. When endotracheal intubation was performed at experienced emergency centers with fiberoptic laryngoscopes, airway management was safely achieved. In addition, if the fractured laryngeal framework was corrected at appropriate times, voice results were good.
Accidents, Traffic ; Airway Management ; Cartilage ; Emergencies ; Hemoptysis ; Hoarseness ; Humans ; Intubation, Intratracheal ; Korea ; Laryngoscopes ; Larynx ; Male ; Medical Records ; Retrospective Studies ; Subcutaneous Emphysema ; Suicide ; Tertiary Healthcare ; Trauma Centers ; Voice

Laryngeal trauma is relatively uncommon but can be possibly life-threatenning. An isolated cricoids fracture associated with neck trauma is rare. We report a case of an isolated multiple fragmented cricoid cartilage fracture that was developed in a 30-year-old man after a neck trauma. It was diagnosed by computed tomography and treated successfully.
Adult ; Cartilage ; Cricoid Cartilage ; Humans ; Larynx ; Neck

BACKGROUND: Mid-ventricular obstruction(MVO) of the left ventricle has been reported to be associated with mid-ventricular hypertrophy, papillary muscle hypertrophy, severe apical hypertrophy, elderly hypertension, and dobutamine stress echocardiography(DSE). The aim of this study is to determine the clinical and echocardiographic features of MVO. METHOD: MVO was defined as systolic hourglass narrowing of the left mid-ventricle in the apical long axis view with turbulent flow exceeding 1m/s. Fifteen patients were suvjected to this retrospective analysis. Baseline patients characteristics were mean age 56(range, 26-74)years, male gender 10(66%). Associated diseases were hypertrophic cardiomyopathy 9, aortic stenosis 1, hypertension without left ventricular hypertrophy(LVH) 1, old myocardial infarction with apical aneurysm 2, stable angina 1, and idiopathic 1. DSE was performed in 7 of 15 subjected patients to evaluate the chest pain. RESULTS: All patients had mild symptoms; chest tightness, palpitation, and weakness, without syncope nor hypotension. MVO was observed in 10 at rest, and 5 after provocation ; DSE 3, VPB 1, atropine 1. Observed peak velocity in the mid-ventricle ranged from 1.2 to 5.5m/s(mean ; 2.8±1.6m/s). Left ventricular outflow tract obstruction defined as the peak flow velocity exceeded 1.5m/s, was also present in 8. in 7 underwent to DSE, systolic blood pressure was changed from 144±15mmHg at rest to 175±28mmHg at peak, heart rate from 73±12/min to 108±23/min, left ventricular end diastolic dimension from 42±5mm to 37±4mm, ejection fraction from 66±10% to 80±6%, and peak flow velocity at the mid-ventricle from 1.0±0.6m/s to 3.3±1.7m/s. CONCLUSION: MVO can be observed in patients without LVH and may account for clinical symptoms of chest discomfort. The mechanism of MVO, at least in part, and be explained with increased ventricular contractility, increased heart rate, and small left ventricular cavity size.
Aged ; Aneurysm ; Angina, Stable ; Aortic Valve Stenosis ; Atropine ; Blood Pressure ; Cardiomyopathy, Hypertrophic ; Chest Pain ; Dobutamine ; Echocardiography ; Echocardiography, Stress ; Heart Rate ; Heart Ventricles ; Humans ; Hypertension ; Hypertrophy ; Hypotension ; Male ; Methods ; Myocardial Infarction ; Papillary Muscles ; Retrospective Studies ; Syncope ; Thorax

BACKGROUND: Idiopathic left ventricular tachycardia (ILVT), one of common idiopathic ventricular tachycardias which develop without structural abnormality of the heart. It has been reported that ILVT has a typical QRS morphology of right bundle branch block and left axis and unique clinical and electrophysiological characteristics. Intravenous verapamil is shown to be very effective in acute termination. However, radio-frequency catheter ablation is now recommended as the treatment of choice for long-term managemnt. This study was performed to determine the clinical and electrophysiological characteristics of ILVT and to evaluate the effects of radiofrequency catheter ablation (RFCA) of ILVT. METHODS: Seventeen patients (12 men, 5 women:mean age : 39+/-15 years) with ILVT were included in this study. ILVT was diagnosed based on the results of electrocardiogram, echocardiogram, cardiac catheterization, and electrophysiology study (EPS). EPS was performed with the standard technique in fasting state for more than 6 hours. In patients with their clinical VTs reproducibly induced during EPS, RFCA was attempted using endocardial activation mapping and pace-mapping. The mode of induction and termination, response to verapamil, and site of origin of the ILVT were evaluated. The local electrogram chacteristics at the sites of successful catheter ablation were also evaluated in patients undergoing RFCA. RESULTS: All 17 patients presented with recurrent palpitation but none with syncope or sudden cardiac death. None had a significant heart disease. The spontaneous ventricular tachycardias were of right bundle branch block morphology with left superior axis in 11 cases, right inferior axis in 1, and northwest axis in 5. The VTs were terminated with intravenous verapamil in all of 14 patients receiving IV verapamil. VT of same morphology as the clinical VT was induced with programmed electrical stimulation in 13 cases (76.4%), of whom 2 cases required isoproterenol infusion. The most frequent mode of induction was single ventricular extrastimulation (7 cases). Mean cycle length of the induced VTs was 320+/-59 ms. RFCA was attempted in 11 cases and successful in 9 (82%). The successful ablation sites were and central mid septum (3 cases), posterior mid septum (3 cases), posterior apical septum (3 patients) of the left ventricle (3 patients). At the successful ablation sites, the local ventricular activation preceded the onset of QRS complex by 34+/-15 ms (range : 10-58) and the paced QRS complexes during pace-mapping were identical to those of the induced or spontaneous VTs in 11.7+/-0.4 leads (range : 11-12). However, Purkinje potential was recorded only in 2 cases. There were no complications associated with EPS and RFCA. CONCLUSIONS: The present study suggests that ILVT is mild in symptoms, highly sensitive to verapamil, mostly caused by reentry, and can be cured by radiofrequency catheter ablation guided by pace-mapping and activation mapping.
Axis, Cervical Vertebra ; Bundle-Branch Block ; Cardiac Catheterization ; Cardiac Catheters ; Catheter Ablation* ; Catheters* ; Death, Sudden, Cardiac ; Electric Stimulation ; Electrocardiography ; Electrophysiology ; Fasting ; Heart ; Heart Diseases ; Heart Ventricles ; Humans ; Isoproterenol ; Male ; Syncope ; Tachycardia, Ventricular* ; Verapamil

BACKGROUND: Idiopathic left ventricular tachycardia (ILVT), one of common idiopathic ventricular tachycardias which develop without structural abnormality of the heart. It has been reported that ILVT has a typical QRS morphology of right bundle branch block and left axis and unique clinical and electrophysiological characteristics. Intravenous verapamil is shown to be very effective in acute termination. However, radio-frequency catheter ablation is now recommended as the treatment of choice for long-term managemnt. This study was performed to determine the clinical and electrophysiological characteristics of ILVT and to evaluate the effects of radiofrequency catheter ablation (RFCA) of ILVT. METHODS: Seventeen patients (12 men, 5 women:mean age : 39+/-15 years) with ILVT were included in this study. ILVT was diagnosed based on the results of electrocardiogram, echocardiogram, cardiac catheterization, and electrophysiology study (EPS). EPS was performed with the standard technique in fasting state for more than 6 hours. In patients with their clinical VTs reproducibly induced during EPS, RFCA was attempted using endocardial activation mapping and pace-mapping. The mode of induction and termination, response to verapamil, and site of origin of the ILVT were evaluated. The local electrogram chacteristics at the sites of successful catheter ablation were also evaluated in patients undergoing RFCA. RESULTS: All 17 patients presented with recurrent palpitation but none with syncope or sudden cardiac death. None had a significant heart disease. The spontaneous ventricular tachycardias were of right bundle branch block morphology with left superior axis in 11 cases, right inferior axis in 1, and northwest axis in 5. The VTs were terminated with intravenous verapamil in all of 14 patients receiving IV verapamil. VT of same morphology as the clinical VT was induced with programmed electrical stimulation in 13 cases (76.4%), of whom 2 cases required isoproterenol infusion. The most frequent mode of induction was single ventricular extrastimulation (7 cases). Mean cycle length of the induced VTs was 320+/-59 ms. RFCA was attempted in 11 cases and successful in 9 (82%). The successful ablation sites were and central mid septum (3 cases), posterior mid septum (3 cases), posterior apical septum (3 patients) of the left ventricle (3 patients). At the successful ablation sites, the local ventricular activation preceded the onset of QRS complex by 34+/-15 ms (range : 10-58) and the paced QRS complexes during pace-mapping were identical to those of the induced or spontaneous VTs in 11.7+/-0.4 leads (range : 11-12). However, Purkinje potential was recorded only in 2 cases. There were no complications associated with EPS and RFCA. CONCLUSIONS: The present study suggests that ILVT is mild in symptoms, highly sensitive to verapamil, mostly caused by reentry, and can be cured by radiofrequency catheter ablation guided by pace-mapping and activation mapping.
Axis, Cervical Vertebra ; Bundle-Branch Block ; Cardiac Catheterization ; Cardiac Catheters ; Catheter Ablation* ; Catheters* ; Death, Sudden, Cardiac ; Electric Stimulation ; Electrocardiography ; Electrophysiology ; Fasting ; Heart ; Heart Diseases ; Heart Ventricles ; Humans ; Isoproterenol ; Male ; Syncope ; Tachycardia, Ventricular* ; Verapamil